Lambeth Education, Health and Care Plan - Parental Request and Information Form
Child details
Child’s Surname
Child’s Preferred First Name
Child’s First Name
Other Names
Address
Date of birth
Gender
Postcode
Home Language
Child’s GP (please include medical centre, practice name and address)
Is your child eligible for Disability Living Allowance?
Yes/No
If yes, which level?
High/Medium/Low
Please tell us the names, addresses and contact details of the parents or carers of your child.
If you share responsibility with someone else who lives at the same address, please write both names in Box 1. If
it is you alone, please write in your name.
By law, we also have to know if anyone else has parental responsibility for your child. Please write their name,
address and contact details in Box 2.
Box 1
Box 2
Name
Name
Address
Address
Postcode
Postcode
Status: Mother/Father/Legal Guardian/Carer (delete as
appropriate)
Status: Mother/Father/Legal Guardian/Carer (delete as
appropriate)
Home phone no.
Home phone no.
Mobile no.
Mobile no.
Email address:
Email address:
Preferred contact method
Preferred contact method
Best time to contact
Best time to contact
What school/college/nursery/setting does your child attend (if applicable) Please include all previous education
settings attended
Setting Name and Address
Dates Attended
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Your request for an EHC assessment will be considered by a panel of professionals from Education, Health and
Social Care, who will discuss whether to go ahead with an assessment, or whether your child’s needs can be
met effectively in other ways.
The needs of the child or young person sits at the heart of the assessment process, so to enable us to decide
whether or not an assessment is appropriate at this stage, we need to know the views, wishes and feelings of
you and your child, along with your aspirations, the outcomes you wish to seek and the support you need to
achieve them.
All about me: My profile and background information (Child/young person’s life story so far…)
Life story so far
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Where and when the child was born
Names of parents/carers and relationship to child/young person, siblings they live with
Medical history (e.g. any medical interventions/surgery/hospital stays/accidents)
Developmental milestones
Other significant family details
How child/young person’s needs and diagnosis impacts on their learning and every day skills (e.g. social
communication, speech and language) if applicable
Specialist services and support offered to date
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Profile
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A summary of how to communicate with the child and engage them in decision-making? Include as
necessary verbal/non-verbal communication, e.g. eye-pointing, gestures, signing and speech. Use of
objects of reference, Makaton, symbols, PECs etc
Health & Medical Needs: For example, asthma, epilepsy, reflux, airway support, medication etc.
Vision/Hearing: How it affects their learning
Drinking/Eating: Include allergies and any dietary and specialist needs e.g. gastrostomy fed
Physical needs and equipment needed: Equipment such as specialist chair, standing frame, splints,
walker, hoist
Self-care and independence: Including personal care if appropriate
other essential information you need to know about: including any sensory issues and special interests
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Child or Young Person’s Views & Aspirations
The child/young person’s views can be demonstrated in a number of ways, e.g. written statement by child/young
person, questionnaires, statement scribed for the child/young person, use of communication aids demonstrated
in picture format, e.g. talking mats/communication books, or use of pictures that are annotated etc. It should be
stated if a child/young person’s views have been written on behalf of them by an adult.
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Things I am good at
Things I like and dislike and new things I would like to try
What is important to me: including who they like to interact with e.g. friendships
What people like and admire about me: e.g. infectious smile, the way he/she laughs, his sociability, her
good sense of humour
What my goals and aspirations are for the future
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Parent/Carer’s views and aspirations
The information you provide below will help us to plan the next steps to support your child to help them
progress in their learning. This will be shared with Early Years/School/College staff and other practitioners
working with your child. Your information will be helpful when planning for support
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Parents/Carer’s aspirations and goals for the future: E.g. to improve communication/interaction with
others, to improve independence skills, thoughts about future provision
Parent/Carer’s views of their child’s special educational needs:
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Have there already been any assessments or observations carried out in relation to your child’s needs? Please
attach copies of any reports.
Please include any school, education, health or social care assessments
Type of assessment
Name and contact details of person carrying out the
assessment
If you currently have a supporter or lead professional supporting you and your child please provide their details:
Name
Service/setting/family member
Address
Phone no
Email
If the Local Authority decides to go ahead with an assessment, would you like us to consider providing you with
support from a Key Worker?
Yes/No (delete as appropriate)
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We need to collect the information in this form so that we can understand what help your child and family
may need. In accordance with the Special Educational Needs and Disability Code of Practice 2014, we are
required to seek further evidence from your child’s school / educational setting. We are also obliged to notify
the following agencies of this request as they may be asked to provide further advice if assessment is agreed.
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Health Authority – Community Services
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Educational Psychology
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Social Care – legally, we must notify Social Services. If they have no involvement with your child, it is
unlikely that they will be asked to the assessment. .
It is also important that you know that we record information on a database electronically and in paper
form that we use to help plan the services we provide.
Declaration – (please tick to confirm your agreement)
I/we give consent to an assessment being undertaken and information regarding our child and family
being shared by and with relevant professionals including those listed above.
Yes/No
(delete as appropriate)
I/we accept that information will be kept on a database to ensure the quality of the service.
Yes/No
(delete as appropriate)
Parent/Carer
Signature:
Date:
Child/Young Person (if over 16 years of age)
Signature:
Date:
Please return this form to: Special Educational Needs, 1st Floor, Olive Morris House, 18 Brixton Hill, London, SW2
1RD
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